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Background: Persistent mortality in adults hospitalized due to acute COVID-19 justifies pursuit of disease mechanisms and potential therapies. The aim was to evaluate which virus and host response factors were associated with mortality risk among participants in Therapeutics for Inpatients with COVID-19 (TICO/ACTIV-3) trials., Methods: A secondary analysis of 2625 adults hospitalized for acute SARS-CoV-2 infection randomized to 1 of 5 antiviral products or matched placebo in 114 centers on 4 continents. Uniform, site-level collection of participant baseline clinical variables was performed. Research laboratories assayed baseline upper respiratory swabs for SARS-CoV-2 viral RNA and plasma for anti-SARS-CoV-2 antibodies, SARS-CoV-2 nucleocapsid antigen (viral Ag), and interleukin-6 (IL-6). Associations between factors and time to mortality by 90 days were assessed using univariate and multivariable Cox proportional hazards models., Results: Viral Ag ≥4500 ng/L (vs <200 ng/L; adjusted hazard ratio [aHR], 2.07; 1.29-3.34), viral RNA (<35 000 copies/mL [aHR, 2.42; 1.09-5.34], ≥35 000 copies/mL [aHR, 2.84; 1.29-6.28], vs below detection), respiratory support (<4 L O2 [aHR, 1.84; 1.06-3.22]; ≥4 L O2 [aHR, 4.41; 2.63-7.39], or noninvasive ventilation/high-flow nasal cannula [aHR, 11.30; 6.46-19.75] vs no oxygen), renal impairment (aHR, 1.77; 1.29-2.42), and IL-6 >5.8 ng/L (aHR, 2.54 [1.74-3.70] vs ≤5.8 ng/L) were significantly associated with mortality risk in final adjusted analyses. Viral Ag, viral RNA, and IL-6 were not measured in real-time., Conclusions: Baseline virus-specific, clinical, and biological variables are strongly associated with mortality risk within 90 days, revealing potential pathogen and host-response therapeutic targets for acute COVID-19 disease., Competing Interests: Potential conflicts of interest. N. R. A. reports support for attending meetings and/or travel to their institution from the National Institutes of Health (NIH). D. L. B. reports consulting fees and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events, and participation on a Data Safety Monitoring Board (DSMB) or Advisory Board with Pfizer, Gilead, MSD, and ViiV; and support for attending meetings and/or travel from ViiV and Gilead. M. K. J. reports a grant to their institution from Gilead Sciences and a contract for a clinical trial to their institution from Regeneron; and a role on the HIV MA Board of Directors. J. P. H. reports consulting fees to the author from Pfizer, MSD, Menarini, Angelini, Zambon, and Tillots; payment or honoraria payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events to their institution and the author from Pfizer and to the author from MSD and Angelini; support for attending meetings and/or travel from MSD and Pfizer; and paid participation as a DSMB member for a TFT Pharmaceuticals clinical trial. K. K. reports grants or contracts to their institution from the NIH, COVID Vaccine Prevention Network, (NIH), Regeneron, Abbott, Pfizer, Romark, and Raisonance; royalties or licenses to book author for Elsevier; consulting fees to the author from Regeneron; payment for expert testimony to the author from the State of Florida; support for travel from Sanford Guide, Burroughs Wellcome Fund, ParaFrap, and the Infectious Diseases Society of America (IDSA) Board of Directors; patents planned, issued, or pending to University of South Florida (USF) F and USF faculty from 3D swabs; leadership or a fiduciary role on the Sanford Guide, Burroughs Wellcome Fund, IDSA board, and ParaFrap; and personal stocks from Gilead. S. L. P. reports grants paid to the University College London, which are completely separate from this work, with Medical Research Council, United Kingdom Research and Innovation, The European and Developing Countries Clinical Trial Partnership, Janssen-Cilag, Gilead Sciences, and ViiV Healthcare; participation as member of the DSMB for the TIPAL trial (The effectiveness and risks of Treating people with Idiopathic Pulmonary fibrosis with the Addition of Lansoprazole: a randomized placebo-controlled multicenter clinical trial). This is an academic trial funded in the United Kingdom by the National Institute for Health and Care Research (NIHR), UK. C. R. reports grants or contracts from NIH and participation on a DSMB or Advisory Board from Mayo Clinic and NIH. U. S. reports research grants or contracts from ViiV Healthcare and AstraZeneca; consulting fees from Shionogi, Paratek, ViiV, and Pfizer; and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Shionogi, Pfizer, and Paratek. B. W. T. reports grants or contracts from Veterans Affairs (VA) Health Services and Development Service Center for Innovations in Quality, Effectiveness, and Safety (13-413), Agency for Healthcare Research and Quality (AHRQ), VA Rehabilitation Research and Development, and Peptilogics; consulting fees from Phiogen; and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from the George Washington ID Board Review Course, the Warren Alpert Medical School of Brown University. A. A. G. reports grants to their institution from Centers for Disease Control, Department of Defense, Faron Pharmaceuticals, and AbbVie; participation on a DSMB or Advisory Board from NIH; and a role on the Scientific Advisory Board from Biomeme. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The role of the circulating leukocytes in lungs and their relationship with circulating proinflammatory cytokines during ischemia-reperfusion injury is not well understood. Using ex vivo lung perfusion (EVLP) to investigate the pathophysiology of isolated lungs, we aimed to identify a therapeutic target to optimize lung preservation leading to successful lung transplantation., Methods: Rat heart-lung blocks were placed on EVLP for 4 hours with or without a leukocyte-depleting filter (LF). After EVLP, lung grafts were transplanted, and posttransplant outcomes were compared., Results: Lung function was significantly better in lung grafts on EVLP with a LF than in lungs on EVLP without a LF. The interleukin (IL)-6 levels in the lung grafts and EVLP perfusate were also significantly lower after EVLP with a LF. Interestingly, IL-6 levels in the perfusate did not increase after the lungs were removed from the EVLP circuit, indicating that the cells trapped by the LF were not secreting IL-6. The trapped cells were analyzed with flow cytometry to detect apoptosis and pyroptosis; 26% were pyroptotic (Caspase-1-positive). After transplantation, there was better graft function and less inflammatory response if a LF was used or a caspase-1 inhibitor was administered during EVLP., Conclusions: Our data demonstrated that circulating leukocytes derived from donor lungs, and not circulating proinflammatory cytokines substantially impaired the quality of lung grafts through caspase-1-induced pyroptotic cell death during EVLP. Removing these cells with a LF and/or inhibiting pyroptosis of the cells can be a new therapeutic approach leading to long-term success after lung transplantation.

Background: Accumulating evidence supports an increasing role of ex vivo lung perfusion (EVLP) in clinical lung transplantation. However, EVLP has adverse effects on the quality of lung grafts, which have rarely been discussed. Careful optimization of current EVLP protocols might improve outcomes. This study examined effects of different levels of oxygenation of the perfusate circulated through the lungs during EVLP and the impact on post-transplant functional outcomes., Methods: We compared results of 4 different oxygenation levels in the perfusate during EVLP: 6% oxygen (O 2 ), 40% O 2 , 60% O 2 , and 100% O 2 . We evaluated lung function, compliance, and vascular resistance and levels of glucose and other markers in the perfusate. After EVLP, lung grafts were transplanted, and post-transplant outcomes were compared., Results: Lungs perfused with 40% O 2 on EVLP had the lowest glucose consumption compared with the other perfusates. Lungs treated with 40% O 2 or 60% O 2 exhibited significantly less inflammation, as indicated by reduced pro-inflammatory cytokine messenger RNA levels compared with lungs perfused with 6% O 2 or 100% O 2 . Significantly more oxidative damage was noted after 4 hours of EVLP perfused with 100% O 2 . After transplantation, lungs perfused with 40% O 2 during EVLP had the best post-transplant functional outcomes., Conclusions: Optimization of O 2 levels in the perfusate during EVLP improved outcomes in this rat model. Deoxygenated perfusate, the current standard during EVLP, exhibited significantly more inflammation with compromised cellular metabolic activity and compromised post-transplant outcomes., (Copyright © 2017 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Background: Adult lung transplant recipients with small chests have traditionally received lungs from pediatric donors, placing an additional strain on the already restricted pediatric donor pool. Performing lobar lung transplantation (LLT) can circumvent issues with donor-recipient size mismatch; however, LLT imparts additional risks. Here, we review our experience using LLT and standard lung transplantation using a pediatric donor (PDLT) for adults with small chests., Methods: We retrospectively reviewed consecutive patients with end-stage lung disease and a height of 65 inches or less who underwent LLT (n = 15) or PDLT (n = 15) between 2006 and 2012 at our institution, a high-volume lung transplant center., Results: Lobar lung transplantation recipients were older (54 ± 10 vs 48 ± 8 years) and had higher pulmonary pressure (57 ± 11 vs 52 ± 27 mmHg) and higher lung allocation scores (70 ± 9 vs 51 ± 8) than PDLT recipients (all P < 0.05). Mean waiting time was 62 days for PDLT and 9 days for LLT. Postoperatively, the incidence of severe primary graft dysfunction and the incidence of acute renal insufficiency were higher, and the mean intensive care unit stay was longer in the LLT group, but the incidence of bronchial anastomotic complications was higher in the PDLT group because of significant size discrepancy in the main bronchus (P < 0.05). Interestingly, long-term functional outcomes and survival rates were similar between the groups., Conclusions: Both LLT and PDLT are viable surgical options for adult patients with small chests. Because of the potential impact on posttransplant outcomes, the technical complexity of transplantation, decisions regarding the best surgical approach should be made by experienced surgeons.

Background: With an increasing number of potential recipients and a comparatively static number of donors, lung transplantation (LT) in the elderly has come under significant scrutiny. Previous studies have been limited by single-center experiences with small population sizes and often mixed results. Using a national registry, we sought to evaluate the following: (1) differences in survival outcomes in septuagenarians compared with sexagenarians; and (2) the effect of temporal trends on the development of other comorbidities in this population., Methods: We analyzed the Scientific Registry of Transplant Recipients (SRTR) data files from the United Network for Organ Sharing (UNOS) database to identify recipients who underwent LT between the years 2000 and 2013. The study period was divided into two equal eras. Using Kaplan-Meier analysis, we compared the 30-day, 3-month, 1-year, 3-year and 5-year patient survival between septuagenarians and sexagenarians in both eras. Separate multivariate analyses were performed to estimate the risk of renal failure, risk of rejection and length of hospital stay (LOS) post-LT in each of these time periods., Results: A total of 6,596 patients were identified comprising 1,726 (26.2%) during 2000 to 2005 and 4,870 (73.8%) during 2006 to 2012. In the "early era," 32 (1.9%) septuagenarians and 1,694 (98.1%) sexagenarians underwent LT, whereas 543 (11.1%) septuagenarians and 4,327 (88.9%) sexagenarians underwent transplantation in the "latter era." A comparison of patient survival between the two groups in the early era revealed no difference at 30 days (95.7% vs 93.8%, p = 0.65). However, 3-month (91.2% vs 75%, p = 0.04) and 1-year patient survival (79.5% vs 62.5%, p = 0.048) were both lower in the septuagenarian group. In the later era, however, there were no differences in 30-day (96.2% vs 96.8, p = 0.5), 3-month (92.7% vs 91.9%, p = 0.56) or 1-year (81.7% vs 78.6%, p = 0.12) patient survival between the two age groups. Survival rates at 3 years (63.7% vs 49.3%, p < 0.001) and 5 years (47.5% vs 28.2%, p < 0.001) were each significantly lower in the septuagenarian group., Conclusion: Overall, LT outcomes for the elderly have improved significantly over time and early outcomes in the modern era rival those found in younger recipients., (Copyright © 2015 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Objective: Improvements in technology have led to a resurgence in the use of extracorporeal membrane oxygenation as a bridge to lung transplantation. By using a national registry, we sought to evaluate how short-term survival has evolved using this strategy., Methods: With the use of the United Network for Organ Sharing database, we analyzed data from 12,458 adults who underwent lung transplantation between 2000 and 2011. Patients were categorized into 2 cohorts: 119 patients who were bridged to transplantation using extracorporeal membrane oxygenation and 12,339 patients who were not. The study period was divided into four 3-year intervals: 2000 to 2002, 2003 to 2005, 2006 to 2008, and 2009 to 2011. With Kaplan-Meier analysis, 1-year survival was compared for the 2 cohorts of patients in each of the time periods. A propensity score-adjusted Cox regression model was used to estimate the risk of 1-year mortality., Results: Of the total number of recipients, 4 (3.4%) were bridged between 2000 and 2002, 17 (14.3%) were bridged between 2003 and 2005, 31 (26.1%) were bridged between 2006 and 2008, and 67 were bridged (56.3%) between 2009 and 2011. Recipients bridged using extracorporeal membrane oxygenation were more likely to be younger and diabetic and to have higher serum creatinine and bilirubin levels. The 1-year survival for those bridged with extracorporeal membrane oxygenation was significantly lower in subsequent periods: 25.0% versus 81.0% (2000-2002), 47.1% versus 84.2% (2006-2008), and 74.4% versus 85.7% (2009-2011). However, this survival progressively increased with each period, as did the number of patients bridged using extracorporeal membrane oxygenation., Conclusions: Short-term survival with the use of extracorporeal membrane oxygenation as a bridge to lung transplantation has significantly improved over the past few years., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Importance: Although early detection and treatment of colorectal cancer has been shown to improve outcomes, geographic proximity may influence access to these services., Objective: To examine the disparities that may exist in colorectal cancer screening and treatment by comparing the distribution of providers of these services in rural and urban counties in the United States., Design, Setting, and Participants: A retrospective population-based study using data obtained from the 2009 Area Resource File for the entire US population within each county., Main Outcomes and Measures: Counties in the United States were categorized as rural or urban using rural-urban continuum codes as our primary exposure. The proportion of gastroenterologists, general surgeons, and radiation oncologists per 100,000 people in each county was estimated as primary outcomes. Multivariate linear regression analysis adjusted for county-level socioeconomic variables, such as percentages of females, blacks, population without insurance, those with a high school diploma, and median household income, to estimate the relative density of each category of these providers between urban and rural counties., Results: In total, 3220 counties were identified, comprising 1807 rural and 1413 urban counties. An unadjusted analysis showed an increased density of gastroenterologists, general surgeons, and radiation oncologists per 100,000 people in urban vs rural counties. A multivariable analysis revealed a significantly higher density of gastroenterologists (1.63; 95% CI, 1.40-1.85; P < .001), general surgeons (2.01; 95% CI, 1.28-2.73; P < .001), and radiation oncologists (0.68; 95% CI, 0.59-0.77; P < .001) per 100,000 people living in urban vs rural counties., Conclusions and Relevance: A rural-urban disparity exists in the density of gastroenterologists, general surgeons, and radiation oncologists who traditionally provide colorectal cancer screening services and treatment. This might affect access to these services and may negatively influence outcomes for colorectal cancer in rural areas.

Rheumatic mitral valve disease often manifests with leaflet fibrosis, commissural fusion and early calcific degeneration. The thickening and fibrosis of the valvular and subvalvular apparatus has made prosthetic mitral replacement the traditional surgical solution. However, favourable valve morphology in some patients may permit a durable mitral repair rather than replacement. There is growing interest in reparative techniques that durably improve the mitral orifice while preserving the subvalvular apparatus. Many of these techniques are technically challenging and require complex resections with intricate chordal adjustments, which may have limited their global acceptance. In this report, we outline a three-step technique that does not require significant resection or involve the use of neochords. This offers a potentially simplified approach to the repair of rheumatic mitral stenosis.

Repair of anterior mitral leaflet (AML) flail is considered to be among the more technically challenging mitral procedures. While neochord reconstruction is an excellent technique, sizing challenges may limit wide reproducibility. Chordal relocation of secondary or tertiary AML chords can minimize sizing imprecision in open or minimally invasive repair while providing patients with a safe, durable and reproducible option. Native chords can be readily released and re-implanted from positions in the body of the leaflet to provide primary AML support, provided there is preservation of ipsilateral papillary muscle alignment. We illustrate the sole use of this reproducible method to repair AML flail.

Introduction: Lung cancer mortality rates may vary with access to specialty providers and local resources. We sought to examine the effect of access to care, using density of lung cancer care providers, on lung cancer mortality among blacks and whites in the United States., Methods: We examined U.S. county-level data for age-adjusted lung cancer mortality rates from 2003 to 2007. Our primary independent variable was per capita number of thoracic oncologic providers, adjusting for county-level smoking rates, socioeconomic status, and other geographic factors. Data were obtained from 2009 Area Resource File, National Center for Health Statistics, and the County Health Rankings Project., Results: Providers of lung cancer care were unevenly distributed among the U.S. counties. For example, 41.4% of the U.S. population reside in counties with less than four thoracic surgeons per 100,000 people, 23.4% in counties with 4 to 15 surgeons per 100,000 people, and 35.3% in counties with more than 15 surgeons per 100,000 people. Geographically, 4.3% of whites compared with 11.2% of blacks lived in high lung cancer mortality zones. Lung cancer mortality did not vary by density of thoracic surgeons or oncology services; however, higher primary care provider density was associated with lung cancer mortality reduction of 4.1 per 100,000 for whites., Conclusion: Variation in provider density for thoracic oncology in the United States was not associated with a difference in lung cancer mortality. Lower mortality associated with higher primary care provider density suggests that equitable access to primary care may lead to reduced cancer disparities.

The existence of disparities within our healthcare system is receiving considerable national attention, as we seek to understand the magnitude of these disparities with the goal of eliminating them altogether. Herein, we review recent important work that captures the current progress in this important area that has direct implications for the thoracic surgeon's daily practice management., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To examine the relationship between race and lung cancer mortality and the effect of residential segregation in the United States., Design: A retrospective, population-based study using data obtained from the 2009 Area Resource File and Surveillance, Epidemiology and End Results program., Setting: Each county in the United States., Patients: Black and white populations per US county., Main Outcome Measures: A generalized linear model with a Poisson distribution and log link was used to examine the association between residential segregation and lung cancer mortality from 2003 to 2007 for black and white populations. Our primary independent variable was the racial index of dissimilarity. The index is a demographic measure that assesses the evenness with which whites and blacks are distributed across census tracts within each county. The score ranges from 0 to 100 in increasing degrees of residential segregation. RESULTS The overall lung cancer mortality rate was higher for blacks than whites (58.9% vs 52.4% per 100 000 population). Each additional level of segregation was associated with a 0.5% increase in lung cancer mortality for blacks (P < .001) and an associated decrease in mortality for whites (P = .002). Adjusted lung cancer mortality rates among blacks were 52.4% and 62.9% per 100 000 population in counties with the least (<40% segregation) and the highest levels of segregation (≥60% segregation), respectively. In contrast, the adjusted lung cancer mortality rates for whites decreased with increasing levels of segregation., Conclusion: Lung cancer mortality is higher in blacks and highest in blacks living in the most segregated counties, regardless of socioeconomic status.

Background: Surgical site infections (SSIs) contribute to increased morbidity, mortality, and hospitalization costs. A previously unidentified factor that may reduce SSIs is the use of local anesthesia. The objective of this study was to determine if the use of local anesthesia is independently associated with a lower incidence of SSIs compared to nonlocal anesthesia., Methods: Using the American College of Surgeons National Surgical Quality Improvement Program database (2005-2007), we identified all patients undergoing surgical procedures that could be performed using local or general anesthesia, depending on the preference of the surgeon. Logistic regression was used to identify factors independently associated with the use of local anesthesia. Propensity matching was then used to match local and nonlocal anesthesia cases while controlling for patient and operative characteristics. SSI rates were compared using a χ(2) test., Results: Of 111,683 patients, 1928 underwent local anesthesia; and in 109,755 cases the patients were given general anesthesia where a local anesthetic potentially could have used. In the unmatched analysis, patients with local anesthesia had a significantly lower incidence of SSIs than patients with nonlocal anesthesia (0.7 vs. 1.4%, P = 0.013). Similarly, after propensity matching, the incidence of SSIs in patients given local anesthesia was significantly lower than for that of patients given nonlocal anesthesia (0.8 vs. 1.4%, P = 0.043)., Conclusions: Use of local anesthesia is independently associated with a lower incidence of SSIs. It may provide a safe, simple approach to reducing the number of SSIs.

The Patient Protection and Affordable Care Act, also known as the House of Representatives Bill HR 3590, was created to improve the quality of patient care and access to health care for American citizens. Provisions of this bill are likely to have both intended and unintended consequences on surgical education. The purpose of this article is to explore the ways in which HR 3590 may affect the educational experience of surgical house officers at teaching hospitals.

As cases of 2009 novel H1N1 influenza became prevalent in Cincinnati, Ohio, Hamilton County Public Health called upon the University of Cincinnati College of Medicine to enhance its surge capacity in vaccination administration. Although the collaboration was well organized, it became evident that a system should exist for medical students' involvement in disaster response and recovery efforts in advance of a disaster. Therefore, 5 policy alternatives for effective utilization of medical students in disaster-response efforts have been examined: maintaining the status quo, enhancing the Medical Reserve Corps, creating medical school-based disaster-response units, using students within another selected disaster-response organization, or devising an entirely new plan for medical students' utilization. The intent of presenting these policy alternatives is to foster a policy dialogue around creating a more formalized approach for integrating medical students into disaster surge capacity-enhancement strategies. Using medical students to supplement the current and future workforce may help substantially in achieving goals related to workforce requirements. Discussions will be necessary to translate policy into practice.

Background: Obesity is disproportionately prevalent among minority patients, yet very little has been written about its effect on surgical outcome in this group., Objective: We investigated the association of body mass index (BMI) category with perioperative complications and resource utilization., Methods: Data from the American College of Surgeons National Surgical Quality improvement Program Participant Use Data File was used to calculate the BMI (kg/m2) of all minority patients undergoing inpatient surgery from 2005 to 2008. Patients were stratified into 4 BMI classes, ranging from normal weight to severely obese. Postoperative length of stay (LOS) was used as the main proxy for resource utilization. Stepwise logistic regression was used to calculate odds ratios for prolonged LOS after controlling for clinically relevant cofactors., Results: Among 73978 patients, 28% were in the normal BMI category, 28.9% were overweight, 28.2% were obese, and 14.9% were severely obese. Morbidity and mortality distribution varied significantly by BMI category, with the highest proportion of cases occurring in the normal-BMI group and the lowest in the severely obese patients. Postoperative LOS was longer for patients in the normal-BMI group than for severely obese patients. Other markers of resource utilization also followed the same pattern with progressive decrease from normal-BMI patients to the severely obese group., Conclusion: Postoperative morbidity and mortality and markers of hospital resource consumption were highest in the normal-BMI patients and decreased progressively to the severely obese group. This group appears to enjoy a paradoxical protection from perioperative complications and so utilize fewer hospital resources.

Paraneoplastic pemphigus is a rare cause of acute diffuse blistering in the adult patient. It commonly presents with subepidermal blistering, epidermal necrosis, and symptoms of mucosal irritation, such as conjunctivitis and vaginal ulceration. Because of its rarity, it is frequently misdiagnosed as Stevens-Johnson syndrome or toxic epidermal necrolysis. In this study, the authors will describe clinical and histologic manifestations of paraneoplastic pemphigus. This case report describes a 45-year-old woman with paraneoplastic pemphigus who was admitted and treated in a burn intensive care unit. Although initially diagnosed with Stevens-Johnson syndrome, the patient had progression of desquamation when potentially offending medications were discontinued. Diffuse adenopathy was noted on examination, and biopsy confirmed a low-grade lymphoma. Paraneoplastic pemphigus is a rare but important cause of acute diffuse blistering in adults. This disorder should be considered in the differential diagnosis of patients with diffuse blistering.

Objective: To compare risk- and volume-adjusted outcomes of colon resections performed at teaching hospitals (THs) vs non-THs to assess whether benign disease may influence the volume-outcome effect., Design: Retrospective data analysis examining colon resections determined by International Classification of Diseases, Ninth Revision, Clinical Modification classification performed in the United States from 2001 through 2005 using the Nationwide Inpatient Sample (NIS) and the Area Resource File (2004). Patient covariates used in adjustment included age, sex, race, Charlson Index comorbidity score, and insurance status. Hospital covariates included TH status, presence of a colorectal surgery fellowship approved by the Accreditation Council for Graduate Medical Education, geographical region, institutional volume, and urban vs rural location. County-specific surgeon characteristics used in adjustment included average age of surgeons and proportion of colorectal board-certified surgeons within each county. Environmental or county covariates included median income and percentage of county residents living below the federal poverty level., Setting: A total of 1045 hospitals located in 38 states in the United States that were included in the NIS., Patients: All patients older than 18 years who had colon resection and were discharged from a hospital included in the NIS., Main Outcome Measures: Operative mortality, length of stay (LOS), and total charges., Results: A total of 115 250 patients were identified, of whom 4371 died (3.8%). The mean LOS was 10 days. Fewer patients underwent surgical resection in THs than in non-THs (46 656 vs 68 589). Teaching hospitals were associated with increased odds of death (odds ratio, 1.14) (P = .03), increased LOS (P = .003), and a nonsignificant trend toward an increase in total charges (P = .36)., Conclusions: With the inclusion of benign disease, colon surgery displays a volume-outcome relationship in favor of non-THs. Inclusion of benign disease may represent a tipping point.

Background: Effective communication and teamwork are critical in many health care settings, particularly the operating room (OR). Several studies have implicated failures of communication and teamwork as the root cause in a high proportion of sentinel events in the OR., Methods: In a prospective cohort study at a high-volume teaching, research, and tertiary care referral hospital, a standardized one-page briefing and debriefing tool was developed and implemented in October 2006 to improve interdisciplinary communication and teamwork in the OR. The briefing portion of the tool was completed by the surgical team after the patient's final positioning and before incision; the debriefing portion was initiated and completed by the circulating nurse after the first counts were conducted. Compliance was calculated as the number of cases where the briefing and debriefing tool was completed divided by the total number of eligible cases. Surveys (n=40) were conducted to elicit caregiver perceptions of interdisciplinary communication and teamwork in the OR and the burden and average time taken to complete the briefing and debriefing tool., Results: Between October 2006 and March 2008, 37,133 briefings and debriefings were conducted. Average compliance varied over time since implementation, with overall compliance ranging from 76% to 95%. The majority of caregivers perceived that the briefing and debriefing tool improved interdisciplinary communication and teamwork. On average, it took 2.9 minutes (range, 1-5 minutes) to complete the briefing portion of the tool and 2.5 minutes (range, 1-5 minutes) to complete the debriefing portion., Discussion: Implementation of a standardized briefing and debriefing tool in a large regional medical center was a, practical and feasible strategy to improve perceptions of interdisciplinary communication and teamwork in the OR.

Hypothesis: The mechanism by which trauma systems improve mortality is unknown. Outcomes may be influenced by experienced trauma surgeons treating more patients (surgeon effect) or improving the overall system of care (system effect). We hypothesized that mortality is lower in patients treated by a fellowship-trained senior trauma program director (experienced) vs first-year general surgery attending surgeon (novice) and that patient mortality for novice surgeons would improve after adding a new senior trauma director., Design: Retrospective cohort study., Setting: Academic level I trauma center., Patients: Individuals who had experienced trauma., Main Outcome Measures: We concurrently compared mortality in trauma patients treated by an experienced trauma surgeon with those admitted by novice surgeons during 5(1/2) years. We also compared mortality in patients treated by novice surgeons before vs after implementation of a more structured trauma program. The chi(2) test and multiple logistic regression analysis were used to compare the groups. Odds ratios (95% confidence intervals) for death were examined., Results: Concurrent comparison of patients treated by novice surgeons vs experienced trauma surgeons demonstrated no difference in mortality (odds ratio, 1.33; 95% confidence interval, 0.82-2.15). At unadjusted univariate analysis, mortality in patients treated by novice surgeons significantly improved over time in the blunt trauma group and all emergency department survivor subgroups. Multivariate analysis demonstrated significantly improved mortality over time in patients treated by novice surgeons (odds ratio, 0.56; 95% confidence interval, 0.37-0.85)., Conclusions: In a structured trauma program, there is no mortality difference between novice surgeons and their experienced trauma director. The organized trauma program and senior surgical mentoring overpower any influence of individual surgeon inexperience.

Background: Minority groups have poor access to quality health care services. This is true of colorectal cancer care and may be related to both geographical proximity and use of surgical, gastroenterology, and radiation oncology services. Without suitable access, many minority patients may present with advanced colorectal cancer and be less likely to receive appropriate adjuvant therapies. We sought to examine the variations in geographical access among minorities at a county level., Design: A retrospective analysis was performed using data from the Area Resource File. Multivariate linear regression analysis was performed to identify the variations in access to colorectal surgeons, gastroenterologists, and radiation oncologists., Setting: All counties in the United States., Participants: Prevalence rate of African Americans and Asian Americans within a county., Main Outcome Measure: Rate of colorectal surgeons, gastroenterologists, and radiation oncologists., Results: Unadjusted analysis revealed that each percentage point increase in the African American population within a county was associated with a decrease in the number of specialists within that county. Multivariate analysis also revealed a statistically significant decrease in the number of gastroenterologists (P < .001) and radiation oncologists (P < .001) with each percentage point increase in the African American population and a trend toward a decrease in colorectal surgeons within that county (P = .28). Each percentage point increase in the Asian American population was associated with a significant increase in the number of gastroenterologists (P < .001) and radiation oncologists (P < .001) with a similar trend toward an increase in the number of colorectal surgeons within that county (P = .13)., Conclusion: Increasing numbers of minority patients in counties is accompanied by a differential access to specialists. This may affect the likelihood of a patient to receive appropriate care.

Background: Black patients with rectal cancer are considerably less likely than white patients to receive adjuvant therapy. We examined the hypothesis that the lower treatment rate for blacks is due to underreferral to medical and radiation oncologists., Methods: We used 1992-1999 Surveillance, Epidemiology, and End Results-Medicare data to identify elderly (> or = 66 years of age) patients who had been hospitalized for resection of stage II or III rectal cancer (n = 2716). We used chi(2) tests to examine associations between race and 1) consultation with an oncologist and 2) receipt of adjuvant therapy. We then used logistic regression to analyze the influence of sociodemographic and clinical characteristics (age at diagnosis, sex, marital status, median income and education in area of residence, comorbidity, and cancer stage) on black-white differences in the receipt of adjuvant therapy. All statistical tests were two-sided., Results: There was no statistically significant difference between the 134 black patients and the 2582 white patients in the frequency of consultation with a medical oncologist (73.1% for blacks vs 74.9% for whites, difference = 1.8%, 95% confidence interval [CI] = > 5.9% to 9.5%, P = .64) or radiation oncologist (56.7% vs 64.8%, difference = 8.1%, 95% CI = > 0.5% to 16.7%, P = .06), but blacks were less likely than whites to consult with both a medical oncologist and a radiation oncologist (49.2% vs 58.8%, difference = 9.6%, 95% CI = 0.9% to 18.2%, P = .03). Among patients who saw an oncologist, black patients were less likely than white patients to receive chemotherapy (54.1% vs 70.2%, difference = 16.1%, 95% CI = 6.0% to 26.2%, P = .006), radiation therapy (73.7% vs 83.4%, difference = 9.7%, 95% CI = 0.4% to 19.8%, P = .06), or both (60.6% vs 76.9%, difference = 16.3%, 95% CI = 4.3% to 28.3%, P = .008). Patient and provider characteristics had minimal influence on the racial disparity in the use of adjuvant therapy., Conclusion: Racial differences in oncologist consultation rates do not explain disparities in the use of adjuvant treatment for rectal cancer. A better understanding of patient preferences, patient-provider interactions, and potential influences on provider decision making is necessary to develop strategies to increase the use of adjuvant treatment for rectal cancer among black patients.

Objectives: Major trauma represents a significant risk for development of deep venous thrombosis (DVT). Duplex ultrasonography is a noninvasive test to identify DVT and has been suggested for screening asymptomatic high-risk trauma patients. While some risk factors for DVT are well described, it remains unclear whether site of DVT development is associated with anatomical location of injury. An association between anatomical locations of injury would serve to highlight the importance of directed screening of those extremities at highest risk. Therefore, we hypothesize that location of DVT correlates with side of lower extremity injury., Methods: We performed an 11-year (1995-2005) retrospective review from the prospectively collected trauma registry at an urban, university-based, level I trauma center. All trauma patients with lower extremity DVT were included. Lateralizing lower extremity injuries were defined as penetrating or blunt injuries affecting only one lower extremity. Fisher's exact test compared concordance between side of injury and side of DVT., Results: A total of 6674 trauma patients were admitted, of whom 40 (0.6%) were diagnosed with lower extremity or pelvic DVT. Mean age of patients with DVT was 39 y, with 80% male, 80% African American, and 55% penetrating trauma. Fourteen patients (35%) with DVT sustained lateralizing lower extremity injuries (6 gunshot wounds, 5 tibia/fibula fractures, 2 femur fractures, and 1 calcaneus fracture). Twelve of these 14 patients (86%) developed DVT on the same side as their injury; (7/7 on right side and 5/7 on left side, P = 0.02). The 26 patients without lateralizing injuries had equal distribution of DVT (39% right, 42% left, and 19% bilateral)., Conclusion: Patients who sustained lateralizing lower extremity injury and developed lower extremity DVT had a high likelihood of developing their DVT on the same side as their injury. A larger multi-institutional analysis is needed to assess the correlation between injury site and anatomical location of DVT before suggesting any changes in recommendations for duplex screening.

Disparities in incidence, mortality, and age of onset of breast cancer between women of African ancestry and women of other racial/ethnic backgrounds are poorly understood. A more comprehensive elaboration of genetic variants that occur in African women may facilitate a better understanding of the disease in African American women and explain the role of genetic admixture on the variation in the expression of the disease. Large-scale, population-based databases that document the cancer burden of Africa are lacking because of financial and infrastructural limitations. The development of such programs would represent an important cancer control and research strategy.

Background: The purpose of this study is to describe practice patterns and outcomes of posttraumatic retrievable inferior vena caval filters (R-IVCF)., Methods: A retrospective review of R-IVCFs placed during 2004 at 21 participating centers with follow up to July 1, 2005 was performed. Primary outcomes included major complications (migration, pulmonary embolism [PE], and symptomatic caval occlusion) and reasons for failure to retrieve., Results: Of 446 patients (69% male, 92% blunt trauma) receiving R-IVCFs, 76% for prophylactic indications and 79% were placed by interventional radiology. Excluding 33 deaths, 152 were Gunter-Tulip (G-T), 224 Recovery (R), and 37 Optease (Opt). Placement occurred 6 +/- 8 days after admission and retrieval at 50 +/- 61 days. Follow up after discharge (5.7 +/- 4.3 months) was reported in 51%. Only 22% of R-IVCFs were retrieved. Of 115 patients in whom retrieval was attempted, retrieval failed as a result of technical issues in 15 patients (10% of G-T, 14% of R, 27% of Opt) and because of significant residual thrombus within the filter in 10 patients (6% of G-T, 4% of R, 46% Opt). The primary reason R-IVCFs were not removed was because of loss to follow up (31%), which was sixfold higher (6% to 44%, p = 0.001) when the service placing the R-IVCF was not directly responsible for follow up. Complications did not correlate with mechanism, injury severity, service placing the R-IVCF, trauma volume, use of anticoagulation, age, or sex. Three cases of migration were recorded (all among R, 1.3%), two breakthrough PE (G-T 0.6% and R 0.4%) and six symptomatic caval occlusions (G-T 0, R 1%, Opt 11%) (p < 0.05 Opt versus both G-T and R)., Conclusion: Most R-IVCFs are not retrieved. The service placing the R-IVCF should be responsible for follow up. The Optease was associated with the greatest incidence of residual thrombus and symptomatic caval occlusion. The practice patterns of R-IVCF placement and retrieval should be re-examined.

sWe describe the management of a cystic duct remnant calculus in a 45-year-old male patient who had undergone a laparoscopic cholecystectomy and re-presented with abdominal pain and jaundice. Magnetic resonance cholangiopancreatography was utilized to confirm the diagnosis of an impacted calculus within the remnant cystic duct along with several small retained common bile duct stones. Four sequential endoscopic procedures successfully removed all retained common bile duct calculi to alleviate the biliary obstruction; however, we were unable to treat the cystic duct remnant calculus endoscopically. The patient finally underwent successful laparoscopic excision of a 2.5-cm cystic duct remnant containing its impacted calculus. It remains unclear if cystic duct remnant calculi may become more prevalent as a cause of postcholecystectomy syndrome in future due to the large numbers of laparoscopic cholecystectomies performed in the past 2 decades.

The most significant advances in the management of small-bowel obstruction are developments in imaging modalities available to assist in the diagnosis itself, as well as to possibly assist in the early identification of those cases requiring urgent operative decompression. The most marked of these have been in the use and interpretation of contrast-enhanced CT. This has decreased the use of barium studies and has largely supplanted ultrasound and magnetic resonance imaging in the management of these patients. Diagnostic and therapeutic laparoscopic techniques are also growing in both capability and popularity. Laparoscopic adhesiolysis and the adjuvant of bioresorbable membranes each hold promise but have yet to become established as standard treatment. Further progress is needed in the detection of early, reversible strangulation. As a consequence, the fundamentals of the surgical management of small-bowel obstruction have evolved little over the past 15 years. With our persistent inability to detect reversible ischemia, a substantial risk of progression to irreversible ischemia remains when surgery is delayed, particularly in the setting of suspected complete obstruction.